Palm Garden of Mattoon: Bed Rail Safety Violations - IL
The resident, identified in inspection records as R7, had a physician's order for a left half side rail specifically to help her move in bed. R7 had already lost her right leg above the knee and was dealing with a fractured left tibia, muscle wasting, and lack of coordination. The rail was supposed to help her. On December 17, 2025, it didn't.
The maintenance director told inspectors he believes nursing staff removed and replaced the rail without securing it to the bed frame properly. That's a problem he described as something that happens often. The Director of Nurses confirmed the rail was not secured, confirmed it posed a hazard, and confirmed only maintenance staff are supposed to touch bed rails at all.
A second resident, R107, fell twice in eight days.
Staff knew for days before her first fall on January 1 that she was dizzy when she stood up. Nobody increased supervision. She fell, developed a large bruise on her sacral area, and was sent to the emergency room complaining of a headache. A week later, on January 8, a therapy staff member walked R107 to the dining room and left without leaving her wheelchair. R107 was supposed to have one. She was scared to walk alone and would have used it. She fell again.
The facility's regional registered nurse told inspectors there is no documentation showing any fall interventions were in place at the time of either fall. She also noted R107 had no bedside table in her room, calling it a standard piece of equipment and saying she didn't know why it was missing.
Palm Garden of Mattoon is disputing the citation.
R107's family told inspectors the January 8 fall was preventable. She wanted the wheelchair. She was afraid. It just wasn't there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of Mattoon from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on January 29, 2026.
The resident, identified in inspection records as R7, had a physician's order for a left half side rail specifically to help her move in bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.